【作者】 范引光；

【导师】 叶冬青；

【作者基本信息】 安徽医科大学 ， 流行病与卫生统计学， 2014， 博士

【摘要】 研究背景在世界各国的共同努力下,近几年全球艾滋病疫情呈下降趋势,新发病例和死亡人数均比2011年有所降低,但艾滋病病毒感染者/艾滋病患者(简称HIV/AIDS)总人数仍呈持续上升的势头,发展中国家艾滋病疫情依然十分严峻。中国属于艾滋病低流行国家,但由于人口基数大,HIV/AIDS绝对数也较大。2007年以来,新发HIV感染人数逐年下降,但其中50岁及以上新发HIV感染者人数及其占新发感染者比例均呈逐年上升的趋势。与年轻的HIV/AIDS相比,50岁及以上的艾滋病患者对有效的抗病毒药物所产生的免疫应答较为缓慢,由HIV感染者发展成为AIDS患者也比年轻人更快。同时,HIV感染、抗病毒治疗和年龄大三者的联合作用增加了50岁及以上HIV感染者和AIDS病人遭受其他慢性病侵害的可能,这些都加速了这一人群的死亡。因此,降低50岁及以上人群的新发感染者数量、遏制该人群HIV感染及死亡持续上升的势头是目前艾滋病防治工作的当务之急,而摸清50岁及以上人群HIV感染的规律,进行有针对性的预防干预则是实现这一目标的前提。国内外研究证实,酒精使用在50岁及以上人群及HIV/AIDS人群中较为普遍,且饮酒是高危性行为的危险因素,饮酒在降低性行为中对安全套预防性传播疾病认知的同时,也会影响饮酒者对安全套使用的态度,并降低饮酒者正确使用安全套的技能,从而提高不安全性行为发生的风险。相对于其他人群而言,国内对于50岁及以上人群艾滋病研究起步较晚,且现有研究多局限于50岁及以上HIV/AIDS对于艾滋病知识、行为的调查及疫情报告,而鲜有针对饮酒在50岁及以上人群HIV感染中所起的作用的报道,鉴于此,本研究拟采用病例对照研究的方法,了解柳州市50岁及以上HIV感染者及健康人群性行为特征及酒精使用的情况,并在此基础上采用条件Logistic回归分析方法揭示饮酒在50岁及以上人群HIV感染中的作用。目的(1)了解柳州市50岁及以上hiv/aidshiv感染的流行病学特征及危险因素;(2)对比分析柳州市50岁及以上hiv/aids与非感染者的饮酒状况及饮酒后高危行为的发生情况;(3)探讨降低柳州市50岁及以上人群过量饮酒及饮酒后高危性行为的对策与措施。方法采用病例对照研究的方法,以艾滋病疫情高发区(广西自治区柳州市和鹿寨县)研究现场,对现住址为柳州市区和鹿寨县、在2010年1月1日-2012年6月30日期间报告的能够随访到的所有50岁及以上hiv/aids为病例,以按照年龄±5岁、性别、居住地相同进行1:1匹配的非感染者为对照进行横断面定量调查,调查内容包括:个人基本信息、饮酒情况、性行为情况、高危行为史、艾滋病知识知晓情况等。同时采用定性调查方法,分别采用不同的访谈提纲对hiv/aids病例、健康对照、疾控中心艾防科工作人员、抗病毒治疗点医生/随访人员、社区卫生服务中心/乡镇卫生院随访人员、vct点工作人员等进行个人深入访谈。定量调查资料使用spss13.0软件进行数据分析,以是否感染hiv状况为结局,采用单因素和多因素统计分析方探讨饮酒、过量饮酒及hiv感染的影响因素,其中单因素分析采用c2检验或fisher确切概率法,多因素分析采用条件logistic回归分析。定性调查资料分析则先把录音转录成文字,然后再根据访谈提纲的条目进行归纳总结。结果1.病例组基本情况:本次调查的528例50岁及以上hiv/aids病例中,84.8%的研究对象通过性接触传播,其中男性主要通过商业异性性行为(67.5%)和非商业偶然异性性行为(11.1%)传播,而女性主要通过固定性伴/配偶阳性(65.5%)和商业异性性行为(19.6%)传播,病例组人群主要通过“其他疾病就医”被发现感染hiv(67.4%),且病例组目前57.0%的个体已经发展为艾滋病人。在367名有配偶/固定性伴的hiv/aids中,92.1%的个体在hiv确诊感染前的配偶/固定性伴性行为中“从来不用”安全套,病例组68.6%的男性发生过商业异性性行为,大部分商业异性性行为发生在本地低档的小旅馆和出租屋,且安全套使用率低,55.5%的被调查者在商业性行为中“从来不用”安全套,不使用安全套的主要原因为“其中一方不愿使用”和“没有必要”。病例组33名发生商业异性性行为的女性均为商业性服务提供者,其工作环境多为本市低档场所或者路边,不使用安全套的原因主要为“其中一方不愿使用”。13.3%的hiv/aids曾发生过非商业偶然性行为,其中,75.7%的对象“从来不用”安全套,而不使用安全套的主要原因为“对方看起来没有病”。病例组人群中有4.7%的个体曾注射吸毒,其中有64.0%的吸毒者有共用针具的行为,本次调查病例组中未见男男同性性行为者。2.hiv感染的影响因素:相对于不饮酒者,轻度饮酒(or=11.957,p=0.029)和较多的商业异性性行为发生次数(or=6.535,p=0.045)是hiv感染的重要危险因素;较高的hiv/aids相关知识得分(or=0.391,p=0.027)为hiv感染的保护性因素。3.饮酒状况及饮酒对性行为的影响:病例组饮酒比例(50.9%)高于对照组(38.4%)(χ2=19.801,p<0.001),病例组和对照组人群主要饮用的酒类为白酒,占所有饮酒者的72.2%,而啤酒的饮用比例略低,为52.8%。在饮酒者中,病例组中过量饮酒的比例(25.3%)高于对照组(18.5%),而有配偶/固定性伴是过量饮酒的保护性因素。病例组过量饮酒者商业异性行为发生比例(90.0%)高于非过量饮酒者(65.1%)(χ2=13.965,p<0.001),而对照组过量饮酒者商业异性性行为(88.2%vs.28.4%,χ2=42.829,p<0.001)及非商业偶然性行为(25.3%vs.7.7%,χ2=9.446,p=0.009)的发生率均高于非过量饮酒者,且对照组过量饮酒者安全套使用情况低于非过量饮酒者(z=2.418,p=0.016)。4.干预措施①加大艾滋病宣传的力度,通过老年人乐于接受的了解艾滋病相关信息的途径如同伴教育、各级医疗机构的医生、报纸、广播及电视进行宣传教育,让50岁及以上人群了解本地区艾滋病疫情的严重性,熟悉生活中可能感染艾滋病的途径尤其是性途径,并针对每一种感染途径,教育大家如何做好自我保护,强调安全套在预防艾滋病传播中所起的作用及如何正确、全程使用安全套;②加强家庭伦理学、法制教育,让其了解婚外性行为违背伦理与道德,且商业性行为是一种违法行为,通过宣传教育增强50岁及以上人群家庭责任感,降低婚外性行为的发生;③加大饮酒与健康的宣传、采用多种形式加强饮酒的健康教育,如开设健康讲座,播放教育录像的方式,让50岁及以上人群了解饮酒与健康的关系、过量饮酒对健康的危害,促进适量饮酒;④加强50岁及以上饮酒者本人的重点教育,对酒精成瘾者进行戒酒治疗、指导其饮酒时尽量饮用低度酒以取代高度酒,减少家庭外集体饮酒的机会,降低过量饮酒及酒后性行为的发生,同时加强安全套使用技能培训,提高酒后性行为中安全套使用率;⑤通过宣传教育,降低50岁及以上人群对艾滋病的恐惧感,让其了解HIV免费检测及治疗的过程和网点,了解自愿检测服务和快速检测的流程,提高该人群高危性行为后自愿咨询检测率。同时,在宣传教育中增加HIV检测阳性后的处理,促进配偶/固定性伴告知及配偶检测,降低HIV在家庭内或配偶/固定性伴间传播。结论柳州地区50及岁以上人群过量饮酒现象比较普遍,应以降低50及岁以上人群过量饮酒及酒后婚外性行为发生率、提高性行为中安全套使用率为指导方针,进一步有效开展艾滋病预防控制及对已发现HIV/AIDS病例的后续随访工作,达到降低HIV新发感染、提高HIV/AIDS生命质量的目的。更多还原

【Abstract】 BackgroundIn recent years, Prevalence of AIDS appears a downward trend, and the rnumber of new cases and dead doll were lower than that of 2011 through the joint efforts of the full participation of all countries in the world, but in developing countries,the situation of HIV infection continues to show an upward tendency. China is a low HIV prevalence country, but the absolute number of HIV/AIDS is big because of the large population in our country. The annual number of new HIV infections has declined since 2007, while the annual number and the proportion of new HIV infection people aged over 50 has increased.Compared with younger patients, HIV/AIDS aged over 50 has lower effective immune response to antivirus drug, and it is faster to develop into AIDS. In addition, the combination of HIV infection, antivirus thrapy and age increase the possibility of suffering other chronic desease in HIV/AIDS aged over 50, which speed up their death, therefore, it is important to prevent and control of HIV/AIDS to decrease the number of new patients aged over 50, and to curb the growth of the HIV infection and death in these people. The most important things is to know the pattern of HIV infection among HIV/AIDS aged over 50 and carry out target prevention program.Studies at home and abroad have confirmed that alcohol consumption was popular in people aged over 50, and alcohol consumption was a risk factor of high risk sexual behavior. Alcohol consumption can decrease the cognition that condom can prevent sexually transmitted disease,in the same time, it can influent the attitude of condom use and decrease the skill of the correct use of condoms.which increase the risk of unprotected sex. In compare with other people, studies carried on HIV aged over 50 in our country is latter, and more research has focused on the knovledge, attitudes and report on epidemic situation, there are fewer research on the effect of alcohol consumption on HIV infection patients aged over 50. for these reasons, this study is to analysis on the alcohol consumption and characteristics of sexual behavior of HIV/AIDS and health people over 50 years old people in Liuzhou city, and the effects of alcohol on HIV infection in people aged over 50 by conditional Logistic regression. bjectives 1.To analysis on the status and epidemiological characteristics of HIV infection of the over 50 years old HIV/AIDS in Liuzhou city. 2.To analysis the different of alcohol consumption status and high risk behaviors after drinking between HIV-infected and non-HIV-infected persons, 3.To explore the prevention strategies and measures to decrease the high risk sexual behaviors after drinking of the over 50 years old people. MethodsCase-control study was conducted among the over 50 years old HIV/AIDS who could be followed up in Liuzhou and Luzhai county from Jan 2010 to June 2012, each HIV case was matched by one non-HIV-infected person paired by age, gender and residence. Questionnaires were used to investigate demographic characteristics, alcohol consumption,high risk behavior, HIV detection, medical-care seeking behaviors and knowledge of HIV/AIDS et al. Qualitative survey was conducted through face to face in-depth interviews among several types of people such as case, control, staff of CDC AIDS prevention department, doctors and follow up staffs in antiviral therapy station, follow up staffs of community health service or health clinics in towns and townships and staffs of VCT clinics. SPSS13.0 was used to analyse the date of quantitative research. HIV/AIDS infection people were divided into two groups basis on infection HIV, which were analysed with univariate analysis and multivariate analysis. In qualitative analysis, recording was transcribed into text firstly, and then a summary method was used to analyze the qualitative data. Results 1. The characteristic of sexual behavior of HIV/AID528 HIV/AIDS aged over 50 were recruited in this study,84.8% of them were infected by sex contact, commercial sex behavior and non-business casual sexual partners were the main transmission, there were 67.5% and 11.1% respectively in male patients, while regular sexual partners or HIV positive spouse and commercial sex behavior were the main transmission in female patients, there were 65.6% and 19.6% respectively, in case group, 67.4% of them were found to be infected with HIV through seeing doctor because of other disease, and 57% of case group were develop into AIDS. In 367 patients who had spouse or regular sexual partners, 92.1% of them did not use condom before diagnosed AIDS, 68.6% of male patients had commercial sex behavior, and most of them had sex trade in inn and rental home and did not use condom, 55.5% of respondents never used condom because of dislike and unnecessary. 33 female HIV/AIDS of case group who had commercial sex behavior were all sex workers, most of them worked at roadside or low grade places in local city, the main reason of not using condom was unlikess. 13.3% of HIV/AIDS patients had happened non-business casual sexual behavior, 75.7% of them never used condom, and the main reason was sex partner seemed healthy.4.7% of case group had ever injected drug,64% of drug users had shared their needles, Men who have sex with men was not found in case group. 2. The risk factors of HIV infectionCompared with non drinkers, Mild drinking(OR=11.957,P=0.029)and more commercial sex trade(OR=6.535, P=0.045) were risk factors of HIV infection,and more higher scores of knowledge of HIV/AIDS(OR=0.391,P=0.027) were protective factors of HIV infection. 3. Alcohol status and its influence on sex behaviorThe percent of alcohol consumption(50.9%)in case group was higher than that’s in control group(38.4%)(χ2=19.801,P<0.001), 72.2% of people from case and control groups drunk liqueur and 52.8% of them drunk beer. The rate of at-risk drinking in case group(25.3%)was higher than control(18.5%), with spouse and regular sex partner were protective factor of at-risk drinking. The rate of commercial sex after at-risk drinking was higher(90.0%) than that of non at-risk drinking in case group(65.1%)(χ2=13.965,P<0.001), while the rate of commercial sex(88.2% VS. 28.4%,χ2=42.829,P<0.001)and non-business casual sexual behavior(25.3% VS. 7.7%, χ2=9.446,P=0.009) of at-risk drinking people were higher than non at-risk drinking in control group. And condom use among people who at-risk drinking was lower than that of non at-risk drinking in control group(Z=2.418,P=0.016). 4. Measurements for decreasing HIV infection among people aged 50 and over ①Propaganda and education on HIV should be strengthened and emphasis on elder people throught their favorite methods as peer education, doctors, broadcast, newspaper and billboard, let people aged 50 and over know the severity of AIDS epidemic in their area and how to prevent HIV infection and the use of condom, and enhance their ability to prevent AIDS. ② It need to strengthen the family ethics and legal education on people aged 50 and over, let them know sex outside marriage is offends against the family ethics and it is a legal behavior so as to reduce or eliminate the sex outside marriage.③Education on alcohol and health should be strengthened to let them know the relationship between alcohol consumption and health, the damage of at-sisk drinking in many ways, such as health talk and video. ④Strengthen the education of people aged over 50 with alcohol, carry out alcohol treatment for alcohol addicts, reduce the incidence of at-risk drinking and sexual behavior after drinking, meanwhile, the trainning of condom use should be strengthen to increase the rate of condom use in sex after drinking. ⑤To reduce and eliminate the feals on AIDS by education, let people know the detecting method and treatment of HIV/AIDS, encourage the people aged 50 and over come to HIV detecting in VCT spot voluntary, meanwhile, improve spouse/sexual-partners notification, to require the HIV/AIDS to notify their spouse/sexual-partners about their HIV-positive status within one month and decrease the rate of HIV transmission in families. ConclusionAlcohol consumption and at-risk drinking were popular in people aged over 50 in Liuzhou city, more work should be took to reduce the incidence of alcohol consumption, at-risk drinking, extramarital sex behavior after drink, and improve condom use in people aged over 50, the program of prevention and control and follow up of HIV/AIDS should be further carry out to decrease the new cases and improve the quality of life.更多还原